U.S. STANDARD CERTIFICATE OF DEATH -- REV. 11/2003

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U.S. STANDARD CERTIFICATE OF DEATH LOCAL FILE NO. STATE FILE NO. 1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last) 2. SEX 3. SOCIAL SECURITY NUMBER 4a. AGE-Last Birthday 4b. UNDER 1 YEAR 4c. UNDER 1 DAY (Years) Months Days Hours Minutes 5. DATE OF BIRTH (Mo/Day/Yr) 6. BIRTHPLACE (City and State …

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